Subjective:
The patient is a 45-year-old female who presents with a chief complaint of shortness of breath and chest tightness for the past 3 days. The patient reports no fever, cough, or other respiratory symptoms. She denies any history of asthma or chronic obstructive pulmonary disease (COPD). The patient reports a past medical history of hypertension, for which she takes lisinopril, and type 2 diabetes, for which she takes metformin. The patient is a non-smoker and reports no recent travel or sick contacts.
Objective:
Vital signs are within normal limits. The physical exam reveals mild inspiratory crackles in the left lung base. Oxygen saturation on room air is 95%. Laboratory tests reveal a normal complete blood count, comprehensive metabolic panel, and D-dimer. Chest X-ray shows mild bilateral infiltrates consistent with viral pneumonia.
Assessment:
Based on the patient’s symptoms, physical exam, and chest X-ray, the working diagnosis is viral pneumonia. The patient’s hypertension and type 2 diabetes are well-controlled and not contributing to her current symptoms. The patient’s oxygen saturation is normal but warrants close monitoring.
Plan:
The patient will be started on a 5-day course of oral azithromycin and advised to continue taking her current medications for hypertension and diabetes. The patient will also be instructed to monitor her oxygen saturation at home and to return to the clinic if her symptoms worsen or if her oxygen saturation drops below 90%. The patient will follow up with her primary care provider in 1 week.
References:
Ebell MH. Diagnosis of pneumonia in adults. Am Fam Physician. 2010;82(7):812-3.
Pavia AT. Viral infections of the lower respiratory tract: old viruses, new viruses, and the role of diagnosis. Clin Infect Dis. 2011;52 Suppl 4:S284-9.
National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute; 2007.
American Diabetes Association. Standards of Medical Care in Diabetes-2018 Abridged for Primary Care Providers. Clin Diabetes. 2018;36(1):14-37.
